Thursday, June 28, 2012

Putting Homeopathy in Historical Context: Part 3

Here’s the story so far: Medicine in the 18th century was kind of a mess. Though people in other scientific disciplines were discovering that the Earth moved around the Sun, that there were laws governing how quickly an apple would fall from a tree, and that stoichiometry could be used to punish generation upon generation of chemistry students, medicine lagged behind this effort.

Samuel Hahnemann was a German physician who grew frustrated at this lack of rigor, and so quit his practice. One day, when translating a recently published medical book, he came across a passage on Cinchona bark that didn’t make sense to him. He took it upon himself to test the effects of Cinchona bark on himself, and discovered that it made him quite ill with symptoms he equated to malaria.

Hahnemann’s goal was to bring to medicine the scientific process he’d seen in other disciplines. Hahnemann believed most strongly that medicines should be tested out before being used to treat disease. The theory that diseases are cured by substances which cause similar symptoms was a result of his experiments.


For most people, this is a very difficult concept to grasp, one that leads to a lot of skepticism, and is also the first concept most encounter when they learn about homeopathy. I have no qualms in saying that, on the face of it, it sounds like nonsense. Coming as we do from a society that has made such advances in understanding how pharmaceuticals, minerals and vitamins interact with enzymes and receptors, and using that knowledge to great advantage, it makes no sense that a medicine that does not obey these pharmacological principles could possibly work. To found a system of medicine on the idea of watering down drugs or herbs would have been as ridiculous in Hahnemann’s time as it would be now (Avogadro would publish in 1811, and though the importance of his work wasn't fully realized at the time, dilution still would have made little sense).

That said, dilution was not the principle upon which Hahnemann founded his new practice – Hahnemann was working with the primary idea that medicine needed to be tested, and that those tests should guide clinical practice. So why did he start diluting?

To answer that question, we need to revisit the tests he did. Hahnemann would only use substances that showed some sort of ‘disease-like’ effect when they were tested out. While not harmful in a small dose, these substances might have ill effects in larger doses (after all, most medicines can cause disease if you consume enough of them). Hahnemann found that most of the time the patient recovered from their illness with no adverse effects, but that in a certain number of patients, he seemed to ‘overdo’ it. The patient would get better at a first dose, still better at a second and third, but the fourth would make the patient sick all over again.

This happened over and over, and even though it didn’t happen to everyone, or indeed that many people, it displeased Hahnemann’s perfectionist tendencies. After trying out a few ways to get around this problem, Hahnemann decided to try diluting the medicines down. To his surprise, this seemed to work better than the other methods he’d tried – he could give a patient multiple doses, they’d keep improving, and he wouldn’t run into that problem of ‘over-dosing’ his patients. Hahnemann was happy, as were his patients. 

As a first concept to be presented with, the concept of dilution is tough at best, but usually considered laughable. That said, I don’t always think it’s presented well or framed in a way that makes sense (we’ll revisit this in next week’s final installment of this series). Unfortunately, framing and PR have a larger role to play in science and medicine than many would like to admit. I often say that many life-saving medical procedures could be made to sound like the plot of a B-grade horror movie if the person telling the story wanted. Of course I’m not suggesting that there’s something wrong with these procedures, I’m just calling to your attention the fact that presentation has a lot to do with reception, and the same applies to homeopathy. Which sounds more appealing: An alternate system of medicine that was the first to pioneer clinical testing of medicines OR A weird system practiced by hippies that’s totally implausible? Let’s not forget that early Christians were persecuted for cannibalism and drinking blood (a rescripting of the Eucharist).

Skeptics often rationalize the effects of homeopathy as being placebo - that the patients have minor complaints that are psychosomatic in nature, and that dilute medicine works just fine because the complaint is in the patient's head. To this suggestion I offer the fact that Hahnemann's time was the time of epidemics and rampant infectious disease - these were his foes, not psychosomatic complaints. Hahnemann gained his reputation by treating very ill patients with gentle medicines.

The 19th Century

Now that we’ve talked about this difficult concept, let’s return to history. From humble beginnings, homeopathy roared to prominence in the 18th century. Many, many physicians practiced homeopathy in Europe and America. Why wouldn’t they? Hahnemann had taken the disorganized world of herbs and therapeutics and had put it in dazzling order. By advocating for testing individual medicines and using the results to guide clinical practice, Hahnemann had brought medicine into the age of reason, and people flocked to it. Additionally, homeopathy offered physicians a method of treatment that avoided the use of barbaric procedures and toxic medicines; for a profession based on the principle of primum non nocere, homeopathy held a lot of appeal.

In the first installment of this series, I asked the question of whether all of these physicians were simply deluded, as opponents of homeopathy might claim. The simple answer is that they weren’t. Homeopathy was very much in keeping with the scientific efforts of the times, and there was a lot of appeal to it.

The development of homeopathy didn’t stop with Hahnemann, either. Throughout the 18th century, many physicians furthered investigations into homeopathy, including testing out new medicines, and working to further organize and systematize the information gathered. It’s a little known fact that in the 1870s, the homeopathic profession in America began developing the idea that in order to get the best results from the tests of medicines, they ought not to tell the test subjects what medicines they were taking. Furthermore, to get even better results, they ought not to tell the clinicians conducting the tests what medicine they were giving. In fact, to get really, really good results, there ought to be placebos given to certain subjects while others received real medicine, and only the people compiling the data would know who received medicine, and who got placebo. While not referred to as a double-blinded, randomized control trials, these efforts clearly foreshadowed what would become the dominant source of medical knowledge starting in the mid-20th century.

So with all of this popularity and effort, what happened? Why is homeopathy a relatively small profession now? Why is it derided by so many? Our stunning conclusion will come next week. I hope you’ll read on.

Monday, June 25, 2012

Two Graphics on Mercury (and Other Junk) in Fish

As I said last week, many of us are trying to get fish into our diets, but it's not an easy task - last week's graphic showed that some fish are healthier than others because of their omega-3 content. Of course, even if a fish is high in omega-3, we might want to avoid it because of mercury, so this week I'm posting two graphics that explain mercury (and other toxin) content in fish.

Here's a little background, as these charts won't include every fish under the sun: When it comes to mercury in fish, the name of the game is biomagnification. What's that? It's the process by which large, predatory fish accumulate higher levels of toxins because they sit higher up the food chain. Mercury enters the ocean's food chain via algae and plankton, but these plants don't accumulate that much mercury. Biomagnification starts with the small fish who feed on the algae/plankton - all of the mercury that was previously 'spread out' amongst a lot of algae now concentrates in the fish who eat them. This process continues further and further up the food chain, with larger and larger fish accumulating larger and larger amounts of mercury, like a pyramid. While we're at it, here's an graphic that demonstrates biomagnification.

This image explains how DDT accumulates in sea birds, but you get the point.

It's big, to be sure, but it's very thorough. This chart is the source document from which a lot of other guidelines are written, so I recommend keeping this handy. (The '*' symbol means that there's significant pressure on wild populations due to fishing, and the '**' symbol is to call your attention to the fact that farm-raised salmon, unlike wild salmon, may contain PCBs and other chemicals.)

The second is from the great state of Vermont, and was published by a collaborative effort between the Department of Environmental Conservation, the Department of Fish & Wildlife, and the Department of Health. I especially like this one because it includes information on fish that you might catch in lakes and rivers. While it's specific to Vermont, the information on this chart is likely applicable in other states as well.

I hope this guides you on your way, and remember, if you don't see the fish you're eating on these charts, you can still estimate its mercury content by thinking about it's feeding patterns - the higher it is on the food chain, the more mercury (and other toxins) you're dealing with. Have a great week and eat well!

Thursday, June 21, 2012

Putting Homeopathy In A Historical Context: Part 2

In last week’s entry, I set the scene onto which homeopathy burst. It was a world in which science and reason were ascending, but very unevenly – where some disciplines were charging forward, many were lagging. Medicine, unfortunately, was one of those that lagged. This uneven development both frustrated and inspired, as we’ll soon see.

Samuel Hahnemann

Samuel Hahnemann got off to rough start as a physician. He transferred his studies between several medical schools, including Leipzig and Vienna, before finally finishing his education in Erlangen. Despite a circuitous course, he ultimately graduated with honors, and was by all measures a very bright man – in addition to his medical training, he was an astute learner of languages, and in addition to his native German was proficient in English, French, Italian, Latin, Greek, and Arabic.

However, I said it was a rough start, and rough it was. He took a physician’s position in a mining town in Saxony, but soon found that the same discontent that drove him to pursue his education at three different universities drove him to be discontented with his chosen career. Hahnemann felt that the practice of medicine was so disorganized, and its medicines so poorly understood, that the treatments sometimes did more harm than good to patients, and so he gave up his practice only a few years after starting it, much to the chagrin of his wife, who thought he was neglecting his young children (he would eventually have eleven children).

Hahnemann wasn’t entirely off-base with his criticisms of medicine. As I’ve said, in Hahnemann’s time, the practice of medicine often involved on the one hand harmful procedures and toxic substances, and on the other a convoluted system of herbs based largely on ancient texts and the notion that herbs’ use could be determined by their appearance. Clinical trials didn’t really exist at this point in time, and so the individual effects of a given herb or treatment were largely unknown – medicines were applied based on theory and opinion, rather than on documented effects. Hahnemann was but one of many people around Europe who felt that there wasn’t nearly enough order and reason in the world around him, and his first response was to throw up his hands and give up.

Der prüfung

In order to support his young children, he fell back on his linguistic skills and got a job as a medical translator. It was in the course of translating William Cullen’s A Treatise on the Materia Medica that Hahnemann came across a passage relating to the treatment of malaria. Cullen stated that cinchona bark was effective against malaria because it was both astringent and bitter, and those properties were what cured malaria (cinchona bark has since been shown to contain quinine). Hahnemann, being the skeptical reader he was, thought this was nonsense. Why should astringency and bitterness make cinchona bark effective against malaria? Weren’t there a whole host of other herbs that were both astringent and bitter, but were of no use against malaria? Hahnemann felt this was symptomatic of medicine in his time – no one knew what any of the individual herbs or chemicals they were using did, they were just guessing.

Hahnemann’s next move was somewhere in the grey zone between madness and genius. It was genius in that Hahnemann was one of the first people in history to test the effect of a single drug in order to determine its use, but it was also mad in that Hahnemann decided to test the effect of Cinchona bark by consuming large quantities of the herb himself. Hahnemann called this experiment a ‘prüfung’, or test, a quite normal word which would eventually be corrupted into English as the obscure ‘proving’, adding to homeopathy’s somewhat anachronistic language.

While the first randomized control trial of a medication wouldn’t be published until 1948, by Hahnemann’s time, there had been some early medical experiments that laid the groundwork for later drug trials – James Lind’s experiments which showed that citrus fruits were an effective treatment for scurvy took place in 1747. Even so, though physicists were learning the laws of force and causality that caused a billiard ball to move after being struck by another billiard ball, this type of thinking – that a unique cause had a unique effect – was only just beginning to enter into medicine (after all, the proof that linked unique germs to unique diseases wouldn’t appear in the medical literature until the 1860’s). In his experiment, Hahnemann was trying to determine causal effect in medicine in a way that was relatively novel. That said, taking a Herculean dose of Cinchona bark was a brave way to go about it.

Some may know this story, others not, but here’s how things panned out for this particular experiment. Hahnemann took a large amount of Cinchona bark, most likely to the great frustration of his long-suffering wife, and found that it made him chilly, drowsy and anxious, made his heart palpitate, and caused him to become slightly feverish. Hahnemann associated these symptoms with those of malaria itself, the very disease Cinchona was meant to cure.

We now know that the quinine in Cinchona bark kills Plasmodium falciparum, the parasite that causes malaria, but Hahnemann, working as he was before germ theory was elucidated, came to a different conclusion. His conclusion was that somehow, something about the fact that the symptoms of cinchona poisoning were so similar to the symptoms of malaria was what caused Cinchona to cancel out or annul malarial symptoms. Somehow, by overlapping, by being similar, the one disease was cured by the other. From this, Hahnemann derived what is called ‘The Law of Similars’, that being that diseases are cured by substances which cause symptoms similar to the disease itself. Hahnemann was working from ideas that had been around since at least the time of Hippocrates, but these ideas had never evolved into a full theory prior to Hahnemann’s experiment.

Medicine at the time worked with the theory that if a patient was hot, to cool them down, and likewise a cool patient should be warmed up, a theory which has become significantly more advanced in the past two hundred years, but which still bears that primary approach – as Dr Andrew Weil says, consider how many classes of drugs start with the phrase ‘anti’, and you’ll get a sense for medical philosophy in practice. Hahnemann’s theory was different – that a cool patient should be given something cool, and then his/her body would warm itself up. Hahnemann rejected the thinking of his time as unscientific and unreasoned, and through trial and experimentation arrived at at his theory.

Next week, we’ll tackle one of homeopathy’s most challenging concepts – dilution of medicines.

Monday, June 18, 2012

A Graphic on Omega-3s in Fish

Last year, the New York Times ran a great article on tilapia, the most-eaten farmed fish in America. Once totally unheard of, tilapia has come racing into the American diet because it is so easily farmed. From a theoretical point of view, fish farming is a perfect solution to many problems - fish are theoretically leaner than red meat or even chicken, farming fish reduces the pressure on wild populations, and the controlled environment means that the fish are less likely to be exposed to certain environmental pollutants. That said, this industry hasn't been without problems - there are concerns about the environmental effects of fish farming on this sort of scale, as well as the food fed to the fish.

I urge you to read the article, but more importantly, I urge you to check out this nifty little graphic they put together on the omega-3 content of fish. Tilapia, largely because of the diet they are fed in farming, rank extremely low on the list. Additionally, farmed tilapia have a relatively high amount of omega-6 fatty acids - a pro-inflammatory fat that is already extremely plentiful in the American diet. Many of us have been urged by our physicians (and especially our cardiologists) to start eating more fish, but it's looking like tilapia isn't the best choice. As you start eating more fish, I hope this chart helps guide you on your way.

Thursday, June 14, 2012

Putting Homeopathy in a Historical Context: Part 1

The Introduction

In the height of the 19th century, homeopathy undoubtedly ruled the day. It was the medicine of choice of intellectuals, the upper class, and the growing middle class on both sides of the Atlantic, and its influence spread all over the world. Many homeopathic medical schools and hospitals were founded, with some of the most famous examples being the Hahnemann Medical College and Hahnemann University Hospital (now both affiliated with Drexel University), as well as the London Homeopathic Hospital, now the Royal London Hospital for Integrative Medicine. Celebrities ranging from Beethoven to Charles Darwin to Mark Twain to the Royal Family were all under the care of homeopathic doctors and there’s even a memorial to Dr Samuel Hahnemann just a few blocks from the White House in Washington DC. It’s no distortion to say that many of the finest minds of the generation were engaged in the practice of homeopathy.

In the early 20th century, however, the system was brought crashingly down. Many colleges and hospitals were closed, and homeopathy lost favor. Currently, most medical doctors and many NDs consider homeopathy to be unsubstantiated nonsense.

How did this change occur? How did a system rise from non-existence to the pinnacle of society and then plummet just as quickly? Were all of these seemingly smart people deluded? Are there lessons to be learned, and is there a place for homeopathy in modern medicine? These are all questions I hope to answer in the next several weeks. I won’t be talking much about the practice of homeopathy, that having been discussed in another blog post, but rather focusing on the history of the system from the 18th century until today.

The Setting

Allow me first to set the scene. Homeopathy arose in the late 18th century, in a time when the Enlightenment was in full sway in Europe. Newton was discovering gravity and calculus, chemistry and physics were racing forward in leaps and bounds, America was developing modern democracy, and on the whole, science was displacing superstition. Carl Linnaeus was an exemplary figure of the age – he developed modern taxonomy in an effort to take the colorful variety of the natural world and order it in a logical and scientific way. Even European cities were changing from knotted tangles of misdirected streets into ordered grids of long straight avenues and boulevards.

Everything seemed to be gaining order except one crucial field – medicine. Medicine hadn’t changed significantly since the time of Galen, 1500 years previously, and modern medicine as we know it wouldn’t really emerge until the 1860’s, when Louis Pasteur, aided by a microscope, would observe and document infective organisms. At the time, diseases were believed to be caused by poisonous gasses called miasma, which emanated from swamps and decomposing matter – those familiar with 18th century literature will perhaps remember references to ‘night vapors’ and similar phenomena as causes of disease. Indeed, the name malaria arises from the Medieval Italian term ‘mala aria’, meaning ‘bad air’ – a testament to the belief that poisonous airs from swamps were the cause of what is now known to be a mosquito-borne illness. These miasma caused illnesses which disrupted the humors, four liquid substances in the body which, when imbalanced, caused illness.

All was not bad, however. Some areas of medicine that had seen real progress during the Renaissance and Enlightenment were anatomy and physiology, in large part because of the return of dissection to science. Scientists and physicians were finally starting to document how the body was put together and how it worked, though this was frequently driven by a desire to find fame, rather than promote real scientific understanding – just as explorers named islands and mountains after themselves, so too did these scientists name body parts after themselves.

However, even though the body was slowly being understood, the area of therapeutics lagged behind substantially – even if they were beginning to understand what the body looked like, and were able to name a disease, they had little idea of what to do with it. George Washington, famously, was bled to death in an effort to fight an infection he’d developed. Bleeding, either by leeches or razors, was common, as was the practice of herbalism by the doctrine of signatures – a practice in which the appearance of a plant was taken to indicate its usefulness in treating disease. In addition to this, developments in chemistry had allowed for the production of a variety of minerals and compounds previously unknown or unavailable in significant quantities, and doctors took to using these compounds medicinally, without much knowledge of how they would affect the body. The classic example of this practice is undoubtedly the use of mercury to treat syphilis.

So this was the milieu in which homeopathy arose – modernity was dawning and people were turning increasingly towards science and reason, but medicine was decidedly medieval and clearly behind the times. It was natural, therefore, for someone to attempt to bring order to the hodgepodge that was medicine, and as we’ll learn in future weeks, that was exactly what happened.

(Note: I am heavily indebted for my knowledge of homeopathic history to Drs Paul Herscu and Amy Rothenberg of the New England School of Homeopathy.)

Monday, June 11, 2012

What Does Your Plate Look Like?

Today's blog is going to be short and sweet, and focus around one important question: What does your plate look like? The 'MyPlate' initiative recently celebrated its first birthday, and in the process became the longest running governmental program that gave people practical advice about eating, rather than presenting confusing, inaccessible information about a theoretical balanced diet. Most Americans eat meal to meal, and the MyPlate initiative gives useful info about what you should eat at any given meal. Of course, some of us might disagree with certain portions of what MyPlate recommends (the recommendation for dairy is likely to be unpopular in certain circles), but the basic recommendation of mainly fruits and vegetables, whole grains, and limited protein is a solid one.

So check this out and think about it. Are you meeting the recommendations? Are you eating better than the recommendations? What exactly is on your plate?

Thursday, June 7, 2012

Is Exercise Bad For You?

It’s well-established at this point that news outlets rarely report positive medical findings with the same enthusiasm as negative medical findings, much in the same way that a young man helping an elderly woman across the street doesn’t garner as much attention as a burglary or fire. Unfortunately, when people get their medical information from local or national news, it often means that doctors end up having to do a lot of explaining.

An example of this phenomenon happened this past week when the New York Times reported that for some people, exercise worsens cardiac risk factors like blood pressure and triglycerides. Of course, this flies in the face of our current understanding of lifestyle and its effects on improving health, and it has some docs worried that their patients may let up on exercise. There are two points that this article has brought up for me, and I hope you find them of help in interpreting this result, a result the lead author termed, ‘bizarre’. (If you're interested, here's the original article)

The first is that, in research, we are constantly bombarded by conflicting information, and that this information needs to be analyzed and understood by clinicians in order to make sense. There’s a somewhat dated expression from the world of computer science that I like to use in this situation: ‘Garbage in, garbage out’. In computing, this means that erroneous entries produce erroneous results, but I mean it to mean that disorganized data results in disorganized opinions. Like the blind men describing the elephant, scientists using separate samples of data will reach differing conclusions, and the data doesn’t organize itself – it’s up to us to gather all of this information and synthesize it into a coherent whole.

When we have data that conflicts with prior information, it’s usually telling us something that we ought to know, and were previously unaware of, but rarely does it supersede the other information or somehow overturn it. Thus, the elephant is in some circumstances is like a rope, in others like a wall, and in others like a tree trunk, but it’s always a large grey mammal. Similarly, this information about exercise is telling us something that we didn’t previously know – what exactly it is hasn’t yet been determined, but in no case does it invalidate the information we already have that in most cases, exercise is linked to decreased risk of hypertension, heart disease, diabetes, depression, cancer, and overall mortality.

The second point to bring up in this discussion is that of outcomes versus surrogate markers. In practicing medicine, our goal is always the preservation of the patient’s health and the alleviation of suffering, because these are the things that happen in real life and that matter to patients. In research terms, they’re outcomes – they are the measurable real life effects we aim to achieve. However, research based strictly on outcomes is expensive, time-consuming, and in certain cases, frought with ethical concerns (think about who would willingly take placebo compared to a potentially life-saving substance). To overcome these obstacles, we instead shoot for shorter goals – these are surrogate markers. Surrogate markers include things like cholesterol, blood sugar, blood pressure, and other similar lab markers or physical exam findings. We use these markers to measure someone’s likelihood of reaching one of the real-life outcomes we’re trying to prevent.

Unfortunately, though these are very useful tools, the link isn’t always perfect. A classic example is that fish oil has a somewhat paradoxical effect of slightly raising LDL cholesterol, but significantly lowers one’s likelihood of having a coronary event. Similarly, many people have escaped having a stroke despite ragingly high blood pressure. In analyzing this data on exercise, then, we have to ask ourselves about markers versus outcomes – this study shows that cardiovascular risk markers are adversely affected in a minority of people who start exercising, but on the other hand, many other studies show that exercise is associated with significantly lower risk of having a cardiovascular event. In my book, outcomes trump markers.

In the end, this information is probably going to tell us something useful. Perhaps a minority of people have a transient elevation of certain markers when they start exercise, that is followed by a long-term lowering of risk factors. Perhaps there is a small subset of people who need specially-tailored exercise programs that won’t cause this elevation. As the authors point out in the paper, we really don’t know what this information means. In the interim, I’m going to continue plugging for the benefits of exercise, because while I believe that important information will come from this surprising finding, I don’t think it’s going to overturn the consensus that exercise is beneficial for the vast majority of people.

Monday, June 4, 2012

A Monday Morning Graphic on Fast Food

It's another Monday, so I'm posting another graphic. This week's image was actually produced by the CDC in an effort to get Americans thinking and talking about the link between fast food and our national weight problem. The increase in portion sizes in the last 50 years has been a major contributor to our now rampant health problems. If you're interested in learning more, I recommend the book Fat Land by Greg Critser. It's relatively short, and pins the rise on a few factors, including high fructose corn syrup and increased portion size. The author links these changes to the economic forces that govern industrialized foods, and makes a strong case in an easily readable format. I highly recommend it, and also recommend thinking about this graphic the next time you're given the option to upsize your meal.